Obsessive-Compulsive and Related Disorders

In the new DSM-5 formulation of psychiatric disorders, obsessive-compulsive disorder is described in a separate chapter of its own apart from other anxiety disorders. It is listed with other OCD Spectrum Disorders, such as Body Dysmorphic Disorder (distorted perception of one’s body), Trichotillomania (hair-pulling disorder), Hoarding Disorder, Excoriation (skin-picking disorder), and Substance/Medication-Induced Obsessive -Compulsive Disorder. More will be said about these disorders in the next section.

The placement of obsessive-compulsive disorder (OCD) in a new chapter of its own is based on both grouping OCD with its associated spectrum disorders as well as certain neurobiological differences in the causes of OCD (and spectrum disorders) from other anxiety disorders.

Some people naturally tend to be more neat, tidy, and orderly than others. These traits can be useful in many situations, both at work and at home. In obsessive compulsive disorder, however, they are carried to an extreme and disruptive degree. Obsessive-compulsive people can spend many hours cleaning, tidying, checking, or ordering, to the point that these activities interfere with the rest of the business of their lives.

Obsessions are recurring ideas, thoughts, images, or impulses that seem senseless but nonetheless continue to intrude into your mind. Examples include images of violence, thoughts of doing violence to someone else, or fears of leaving on lights, leaving on the stove or leaving your door unlocked. You recognize that these thoughts or fears are irrational and you try to suppress them, but they continue to intrude into your mind for hours, days, weeks, or longer. These thoughts or images are not merely excessive worries about real-life problems and are usually unrelated to a real-life problem.

Compulsions are behaviors or rituals that you perform to dispel the anxiety brought up by obsessions. For example, you may wash your hands numerous times to dispel a fear of being contaminated, check the stove again and again to see if it is turned off, or look continually in your rearview mirror while driving to assuage anxiety about having hit somebody. You realize that these rituals are unreasonable, yet you feel compelled to perform them to ward off the anxiety associated with your particular obsession. The conflict between your wish to be free of the compulsive ritual and the irresistible desire to perform it is a source of anxiety, shame, and even despair. Eventually you may cease struggling with your compulsions and give over to them entirely.

Obsessions may occur by themselves, without necessarily being accompanied by compulsions. In fact, about 20 percent of the people who suffer from obsessive compulsive disorder only have obsessions, and these often center around fears of causing harm to a loved one or having disquieting sexual thoughts.

The most common compulsions include washing, checking, and counting. If you are a washer, you are constantly concerned about avoiding contamination. You avoid touching doorknobs, shaking hands, or coming into contact with any object you associate with germs, filth, or a toxic substance. You can spend literally hours washing hands or showering to reduce anxiety about being contaminated.

Women more often have this compulsion than men. Men outnumber women as checkers, however. Doors have to be repeatedly checked to dispel obsessions about being robbed; stoves are repeatedly checked to dispel obsessions about starting a fire; or roads repeatedly checked to dispel obsessions about having hit someone. In the counting compulsion, you must count up to a certain number or repeat a word a certain number of times to dispel anxiety about harm befalling you or someone else.

Obsessive-compulsive disorder is often accompanied by depression. Preoccupation with obsessions, in fact, tends to wax and wane with depression. This disorder is also typically accompanied by phobic avoidance—such as when a person with an obsession about dirt avoids public restrooms or touching doorknobs. Sometimes avoidance interferes with the person’s social or occupational functioning.

It is very important to realize that as bizarre as obsessive-compulsive behavior may sound, it has nothing to do with “being crazy.” You usually recognize the irrationality and senselessness of your thoughts and behavior, and you are very frustrated (as well as depressed) about your inability to control them. Obsessive-compulsive disorder is different from compulsive behavior disorders such as gambling and overeating. People with compulsive behavior disorders derive some pleasure from their compulsive activities, whereas people with OCD neither want to perform their compulsions (except to reduce fear) nor derive any pleasure from doing so.

In the new DSM-5 diagnostic manual, there are diagnostic specifiers to indicate those few people who have little or no insight into their OCD beliefs being illogical.

Obsessive-compulsive disorder used to be considered a rare behavior disturbance. However, recent studies have shown that about two to three percent of the general population may suffer, to varying degrees, from obsessive-compulsive disorder. The reason prevalence rates have been underestimated up to now is that most sufferers have been very reluctant to tell anyone about their problem. Women seem to be affected slightly more than men, but boys are more commonly affected in childhood than girls. The average age of onset of OCD is 19.5 years. Onset of symptoms is typically gradual. Without treatment, remission of OCD in adulthood is low, typically less than 20 percent. With effective treatment, partial to full recovery is possible in up to 60 percent of cases.

The causes of obsessive-compulsive disorder are unclear. There is some evidence that a deficiency of a neurotransmitter substance in the brain known as serotonin, or a disturbance in serotonin metabolism, is associated with the disorder. This is borne out by the fact that many sufferers improve when they take medications that increase brain serotonin levels, such as clomipramine (Anafranil) or specific serotonin-enhancing antidepressants such as fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), or escitalopram (Lexapro). It also appears that persons with OCD have excessive activity in certain parts of the brain, such as the prefrontal cortex and the caudate nucleus.

OCD has a high degree of heritability, with 57 percent of identical twins both showing symptoms of the disorder versus 22 percent of fraternal twins.

Current Treatment

Relaxation Training
As with all of the anxiety disorders, abdominal breathing and deep relaxation skills are practiced on a daily basis to help reduce anxiety symptoms.

Cognitive Therapy
Fearful, superstitious, or guilty thoughts associated with obsessions are identified, challenged, and replaced. For example, the idea “If I have a thought of doing harm to my child, I might act on it” is replaced with “The thought of doing harm is just random noise caused by the OCD. It has no significance. Just having the thought doesn’t mean I’ll do it.”

Exposure and Response Prevention (ERP)
This technique consists of exposure to situations that aggravate obsessions, followed by enforced prevention from performing rituals or compulsions. For example, if you’ve been washing your hands every time you touch a doorknob, you’d be instructed to touch doorknobs and either reduce the number of times you wash your hands or refrain from washing at all. Similarly, if you check the door five times whenever you leave your house, you would be required to gradually reduce the number of checks to one.

You and your therapist devise a variety of situations, preferably in your home setting. Then you continually practice exposing yourself to these situations and desist from performing the compulsions (response prevention). Usually your therapist or a support person accompanies you to monitor your compliance in not performing compulsions.

When your problem involves obsessions only, without compulsions, any neutralizing thoughts or covert rituals you use to reduce anxiety caused by your obsessions need to be stopped. You would also work on accepting your obsessions without trying to make them go away. (For further information on exposure and response prevention in treating OCD, see the book Stop Obsessing: How to Overcome Your Obsessions and Compulsions by Edna Foa and Reid Wilson, or The OCD Workbook by Bruce Hyman and Cherry Pedrick.)

Medications such as Anafranil and the SSRI medications, including Prozac, Luvox, Lexapro, Celexa, and Zoloft, help about 60 to 70 percent of those with OCD. Long-term use of medication is fairly common with OCD, although in some cases the cognitive therapy and exposure/response prevention strategies described above may suffice. Effective doses of SSRI medications are usually higher for OCD than for other anxiety disorders, and benefits from these medications tend to appear only after two to three months at higher doses. Low doses of antipsychotic medications such as Zyprexa and Resperdal have been found to be useful adjuncts in the treatment of OCD for some people, which indicates that part of the brain mechanisms underlying OCD involve the role of dopamine receptors. The use of SSRI medications is often part of the normal treatment protocol for OCD. It is necessary to take the medication long term, as discontinuation often results in a return of the original OCD symptoms.

Lifestyle and Personality Changes
Essentially, the same lifestyle and personality changes described for panic disorder and generalized anxiety disorder apply to OCD.

The strategies presented in this website will be helpful if you are affected by obsessive-compulsive disorder. Because OCD is often a severe and debilitating problem, it is highly recommended that you consult a professional who is well versed in the use of behavioral methods, such as exposure and response prevention, as well as in the use of appropriate medications. This site can complement behavioral and pharmacological treatment approaches.

OC Spectrum Disorders

OC Spectrum Disorders share commonalities in their neurobiological basis with OCD. They include Body Dysmorphic Disorder, a preoccupation with perceived flaws or defects with physical appearance; Hoarding Disorder, a difficulty with discarding possessions that results in significant clutter in one’s personal living area; Trichotillomania, a recurrent pulling out of one’s hair (resulting in noticeable hair loss) with repeated attempts to decrease or stop pulling; and Excoriation, recurrent skin picking (resulting in lesions) with repeated attempts to stop. OC Spectrum Disorders have become a specialty area of their own and are typically treated by therapists who specialize in OCD, and who adopt exposure and response prevention techniques to the specific spectrum disorder involved.

Several other OCD-related disorders are mentioned in the full DSM-5 chapter on OCD. These include instances where OCD or OCD spectrum disorders can be directly attributed to a medical condition, or appear to be manifestations of substance-induced intoxication or withdrawal symptoms.